— 心理社會完整性 · EASY · MCQ —
一位 45 歲焦慮症病人出現心悸、震顫及瀕死感。護理師首要介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations, tremors, and a sense of impending doom. Which intervention is the highest priority for the nurse?
- APerform a comprehensive head-to-toe assessment進行全面的頭到腳評估
- BEncourage the client to discuss the source of anxiety鼓勵病人討論焦慮的來源
- CAdminister an anxiolytic medication給予抗焦慮藥物
- DRemain with the client to provide support✓ 正解留在病人身邊提供支援
— Explanation · 中文詳解 —
焦慮症發作時，病人的生理與心理處於高度不穩定狀態，瀕死感（sense of impending doom）常伴隨過度換氣與生理徵象改變。護理師的首要任務是提供安全感（Safety），透過「陪伴」來減輕病人的恐懼與孤獨感，這是最直接的心理支持介入。藥物給予及深度評估均需在病人情緒平穩後進行，陪伴則是穩定病人的第一步。
During an acute anxiety attack characterized by palpitations and a sense of impending doom, the nurse's priority is to remain with the client to provide a sense of safety and reduce feelings of isolation. This supportive presence is the most immediate intervention, deep exploration or medication administration should occur only after the client has stabilized.